Provider Demographics
NPI:1023027976
Name:PRINCE, MARVIN D (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:D
Last Name:PRINCE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 N. ELDORADO AVE.
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-882-8158
Mailing Address - Fax:
Practice Address - Street 1:MERLE WEST MEDICAL CENTER
Practice Address - Street 2:2865 DAGGETT ST
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-883-6263
Practice Address - Fax:541-883-6216
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist